On December 30, 2009 the Centers for Medicare & Medicaid Services (CMS) released the proposed rule that would implement provisions of the American Recovery and Reinvestment Act of 2009 (ARRA) that will provide the EHR incentive payments and wow what a rule – 554 pages worth!! The good news is, if you have an interest in this subject, the document was quite readable and very informative.

Since the feeding frenzy started surrounding ARRA/HITECH stimulus money, many questions and interpretations have appeared on blogs and articles authored by the normal healthcare pundits and experts - some accurate, some not so much. The CMS proposed rule provides significant clarity to those questions and interpretations. The proposed rule provides clarity around a range of topics from definitions of Eligible Providers (EPs), to proposals that Medicare and Medicaid use the same EHR incentive calculations, to defining exactly what it means when asked to report on the patients with their hemoglobin A1c (HbA1c) under control. The data is fantastic information and is vital to helping vendors, institutions, consultancies and government agencies understand the parameters to becoming and declaring Meaningful Use (MU).

In fact, the rule makes declaring Meaningful Use for Year One relatively straightforward. The parameter to be a Year One Meaningful User is “any continuous 90-day period within the first payment year”. In fact, an EP can declare meaningful use for the Medicaid Incentive in calendar year 2010 simply by “adopting, implementing or upgrading certified EHR technology” and complying with the 26 MU criteria. Add to this that Year One is certified via attestation from the site. Initial reaction – hey not so bad, most places can do this!!!

Then comes Year Two. In the words of Bette Davis - “Fasten your seatbelts, it's going to be a bumpy night!” Year Two requires 100% compliance with 100% of the requirements 100% of the time with electronic submission of proof (as long as CMS has the technical infrastructure in place to support electronic submission). A few examples of this quantum leap in requirements:

• Year One - EPs need to use CPOE for 80% of all orders, Hospitals 10% of all orders, while in Year 2 – 100% of orders are required for both!
• Year One - At least 80% of all unique patients seen by the EP or admitted to the eligible hospital have at least one entry of an up-to-date problem list of current and active diagnoses based on ICD-9 CM or SNOMED CTâ or indication of none recorded. Year 2 – 100%!

These types of leaps in requirements are throughout the document. Is this fair, some will say yes, some will say no – I say beware.

Let’s further investigate CPOE. Deploying and using CPOE for things like dietary orders and simple lab tests are reasonably straightforward and quite doable. Difficulties arise in specialty areas such as a NICU where orders can be weight-based, age–based and so on. These specialty areas place significant stress on CPOE systems and the teams deploying them. So what’s my point, if a hospital declares meaningful use 90 days prior to the end of the first payment year and uses dietary and other important, but reasonably straightforward orders, to attain the 10% Meaningful Use bogie – Year One will be a somewhat easy to achieve success. If that same hospital waits to really tackle the hard stuff, e.g., NICU, for Year Two - the odds of 100% compliance, 100% of the time may be about as good as being struck by lightening during the year (which by the way are 1:500,000). What is even more striking is, this example only addresses the mechanics of building the order sets in a systems and getting that right, challenges such as workflow impact, increases in ordering time and overall adoption strategies will present an entirely new set of issues, all of which will impact Meaningful Use.

Similarly for problem lists, there are two components here – one is the standardized vocabularies (ICD 9 CM and SNOMED CTâ), if a site has not instituted them the challenge is very significant and will require retraining of the business office staff as well as admission clerks. The other challenge is the words “all unique patients”. Unique is the key here – unique means that if I show up for multiple visits or multiple admissions I am counted once. In contrast if the rule simply said all patients – this would basically equate to the number of admissions or visits. Unique imposes a set of really unique issues – what if I have multiple medical record numbers, what if the site does not have some sort of Master Patient Index (MPI) to name just one – this could wreak havoc on the “all unique patients” requirement and the result could be failure to sustain Meaningful Use.

In addition to the Meaningful Use requirements, we cannot ignore the ICD-10 migration that must be complete by October 1, 2013. This conversion, by any metric, is a huge task in conversion and retraining. When the required ICD-10 migration is combined with MU requirements the amount of change introduced into most care delivery systems will overflow their proverbial cup if they are not prepared. It will stress the clinical staff, the IT staff, Executive Leadership – no one will be immune. So there are really two approaches to this – become an ostrich with your head in the sand or develop a plan to manage to. The latter is much more preferable.

So wrapping this one up, I live in Texas and at each railroad crossing there is a sign that says – stop, look, listen. Since many railroad crossings in this state are unprotected this is sage advice. I would suggest that each of us heed this warning and stop, look, listen and plan for not only how to attain and declare meaningful use, but more importantly how to ensure meaningful use is sustained over the long haul.

For information on how Santa Rosa Consulting can provide the expertise and innovative approaches to help your institution attain, maintain and realize the clinical and financial benefits of meaningful use please contact us at http://www.santarosaconsulting.com and click on contactus@santarosaconsulting.com.